Assessing the Race, Ethnicity, and Gender Inequities in Blood Alcohol Testing After Trauma.

INTRODUCTION: Alcohol use remains a significant contributing factor in traumatic injuries in the United States, resulting in substantial patient morbidity and societal cost. Because of this, the American College of Surgeons Verification, Review, and Consultation Program requires the screening of 80% of trauma admissions. Multiple studies suggest that patients who use alcohol are subject to stigma by health care providers and may ultimately face legal and financial ramifications of a positive alcohol screening test. There is also evidence that sociodemographic factors may dictate drug and alcohol screening patterns among patients. Because this screening target is often not uniformly achieved among all patients presenting with injury, we sought to investigate whether there are any discrepancies in screening across sociodemographic groups. METHODS: We investigated the Trauma Quality Program Participant User File for all trauma cases admitted during 2017 and compared the rates of the serum alcohol screening test across different demographic factors, including race and ethnicity. We then performed an adjusted multivariable logistic regression to determine the odds ratio (OR) for receiving a test based on these demographic factors adjusted for hospital and clinical factors. RESULTS: There were 729,174 traumas included in the study. Of this group, 345,315 (47.4%) were screened with a serum alcohol test. Screening rates varied by injury mechanism and were highest among motorcycle crashes (66.0% of patients screened) and lowest among falls (32.8% of patients screened). Overall, Asian and Pacific Islander (52.5% screened), Black (57.7% screened), and other race (58.4% screened) had higher rates of alcohol screening than White patients (43.7% screened, P < 0.001). Similarly, Hispanic patients were screened at higher rates than non-Hispanic patients (56.4% screening versus 46.2% screening, P < 0.001). These differences persisted across nearly all injury categories. In multivariable logistic regression, Asian and Pacific Islanders were associated with the highest odds of being screened (OR 1.34, P < 0.001) followed by other race (OR 1.25, P < 0.001) in comparison to White patients. CONCLUSIONS: There are consistent and significant differences in alcohol screening rates across race and ethnicity, despite accounting for injury mechanism and comorbidities.

Clinical significance of "positive" cervical spine MRI findings following a negative CT.

PURPOSE: To review and analyze the clinical significance of positive acute traumatic findings seen on MRI of the cervical spine (MRCS) following a negative CT of the cervical spine (CTCS) for trauma. METHODS: We performed a sub-cohort analysis of 54 patients with negative CTCS and a positive MRCS after spine trauma from the previous multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Both CTCS and MRCS were independently reviewed by two emergency radiologists and two spine surgeons. The surgeons also commented on the clinical significance of the traumatic findings seen on MRCS and grouped them into unstable, potentially unstable, and stable injuries. RESULTS: Among 35 unevaluable patients, MRCS showed one unstable (hyperextension) and two potentially unstable (hyperflexion) injuries. Subtle findings were seen on CTCS in 2 of 3 patients upon careful retrospective review that would have suggested these injuries. Of 19 patients presenting with cervicalgia, 2/5 (40%) patients with neurological deficit demonstrated clinically significant findings on MRCS with predisposing factors seen on CT. None of the 14 patients with isolated cervicalgia and no neurological deficit had clinically significant findings on their MRCS. CONCLUSION: While CTCS is adequate for clearing the cervical spine in patients with isolated cervicalgia, MRCS can play a critical role in patients with neurological deficits and normal CTCS. Clinically significant traumatic findings were seen in 8.5% of unevaluable patients on MRCS, though these injuries in fact could be identified on the CT in 2 of 3 patients upon careful retrospective review.

Anticoagulation is Associated with Increased Mortality in Splenic Injuries.

INTRODUCTION: Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients. RESULTS: A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.

Choosing the Best Approach to Warfarin Reversal After Traumatic Intracranial Hemorrhage.

BACKGROUND: Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS: This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS: Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS: Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.

Hospital Volume and Operative Mortality for General Surgery Operations Performed Emergently in Adults.

OBJECTIVE: This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk? BACKGROUND: Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies. METHODS: Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality. RESULTS: A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair. CONCLUSIONS: Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.

Insurance Status Biases Trauma-system Utilization and Appropriate Interfacility Transfer: National and Longitudinal Results of Adult, Pediatric, and Older Adult Patients.

OBJECTIVE: To identify the association between insurance status and the probability of emergency department admission versus transfer for patients with major injuries (Injury Severity Score >15) and other complex trauma likely to require higher-level trauma center (TC) care across the spectrum of TC care. BACKGROUND: Trauma systems were developed to facilitate direct transport and transfer of patients with major/complex traumatic injuries to designated TCs. Emerging literature suggests that uninsured patients are more likely to be transferred. METHODS: Nationally weighted Nationwide Emergency Department Sample (2010-2014) and longitudinal California State Inpatient Databases/State Emergency Department Databases (2009-2011) data identified adult (18-64 yr), pediatric (≤17 yr), and older adult (≥65 yr) trauma patients. Risk-adjusted multilevel (mixed-effects) logistic regression determined differences in the relative odds of direct admission versus transfer and outcome measures based on initial level of TC presentation. RESULTS: In all 3 age groups, insured patients were more likely to be admitted [eg, nontrauma center (NTC) private vs uninsured odds ratio (95% confidence interval): adult 1.54 (1.40-1.70), pediatric 1.95(1.45-2.61)]. The trend persisted within levels III and II TCs (eg, level II private vs uninsured adult 1.83 (1.30-2.57)] and among other forms of trauma likely to require transfer. At the state level, among transferred NTC patients, 28.5% (adult), 34.1% (pediatric), and 39.5% (older adult) of patients with major injuries were not transferred to level I/II TCs. An additional 44.3% (adult), 50.9% (pediatric), and 57.6% (older adult) of all NTC patients were never transferred. Directly admitted patients experienced higher morbidity [adult: 19.6% vs 8.2%, odds ratio (95% confidence interval):2.74 (2.17-3.46)] and mortality [3.3% vs 1.8%, 1.85 (1.13-3.04)]. CONCLUSIONS: Insured patients with significant injuries initially evaluated at NTCs and level III/II TCs were less likely to be transferred. Such a finding appears to result in less optimal trauma care for better-insured patients and questions the success of transfer-guideline implementation.

Postoperative delirium is associated with increased intensive care unit and hospital length of stays after liver transplantation.

BACKGROUND: Delirium is increasingly recognized as a common and important postoperative complication that significantly hinders surgical recovery. However, there is a paucity of data examining the incidence and impact of delirium after liver transplantation. METHODS: Retrospective case series in a tertiary care center examining all (n = 144) adult patients who underwent liver transplantation during a 6-y period. RESULTS: Delirium occurred in 25% of the patients with an average duration of 4.56 d. Patients who developed delirium were older (P = 0.007), had higher preoperative model for end-stage liver disease score (P = 0.019) and longer pretransplant hospital length of stay (LOS; P = 0.003). Patients with delirium were also more likely to have alcohol ingestion as an etiology of the liver failure (P = 0.033). Delirious patients had a trend toward increased ventilator days (P = 0.235) and significantly longer postoperative hospital (P = 0.001) and intensive care unit LOS (P = 0.001). Delirium was also associated with an increased frequency of hospital acquired infections including urinary tract infections (P = 0.005) and pneumonias (P = 0.001). CONCLUSIONS: Delirium is a common occurrence among liver transplant patients associated with increased complications and LOSs. Further prospective studies are needed to determine the specific risk factors in this complex population and to determine if delirium has an impact on long-term outcomes.

Uncertainty Among Acute Care Surgery Providers Does Not Change with Experience.

BACKGROUND: Acute care surgery (ACS) is a demanding profession that is by its na- ture unpredictable and requires practitioners to routinely deal with uncertainty and stress. We hy- pothesized that the field attracts people who are comfortable working in such an environment and that their comfort with uncertainty increases with experience. A surgeon's stress with uncertainty can be assessed usingthe previouslyvalidated Physician Reaction to Uncertainty Scale (PRU scale). METHODS: After approval from our IRB and the Eastern Association for the Surgery of Trauma (EAST) Research and Scholarship Committee, an online-survey was sent to EAST members. The survey included demographic questions and the PRU scale. 'The PRU scale requires answering 15 questions on a scale of one to six (strongly disagree to strongly agree) with four subsections measuring anxiety to uncertainty, concern about outcomes, reluctance to disclose uncertainty to patients, and reluctance to disclose mistakes to physicians. A higher score represents greater discomfort. Survey requests were sent to 1707 members; 424 surveys were complete and used for analysis. RESULTS: Most respondents were surgeons (92.4%) and male (77.1%). Average total score was 40.4/90. Overall discomfort with uncertainty on the PRU scale did not vary with gender (p = .88), experience (P=.11), age (P=.21), or practice location (P=.26). With increased experience, there was decreased re- luctance to disclose uncertaintyto patients (P = .03) and a trend to decreased anxiety about outcomes (P=.09). CONCLUSION: Overall discomfort with uncertainty among ACS providers appears to be inherent in their personality and does not change over a career span.'Ihis factor may play a role in the development of occupational stress since discomfort with uncer- tainty appears to persist over time. Future studies looking at other surgical specialties for comparison and atlongitudinal studies may provide insight into the personality of the community.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Mechanical ventilation after injury.

Injury is a major cause of critical illness worldwide. Severely injured patients often require mechanical ventilation not only to manage primary respiratory failure but also as adjunct to manage other conditions. Injury induces fundamental changes in multiple organ systems which directly impact ventilator management; these changes are not shared by patients without concomitant tissue injury. In this article, we review the physiologic changes after injury and discuss the impact of injury on ventilator strategies and management. We also explore the special considerations in patients with traumatic brain injury, thermal injury, blast injury or bronchopleural fistula.

Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

INTRODUCTION: Whole blood resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of whole blood-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether whole blood should be considered in civilian trauma patients receiving blood transfusions. METHODS: An EAST working group performed a systematic review and meta-analysis utilizing the GRADE methodology. One PICO question was developed to analyze the effect of whole blood resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and ICU length of stay. English language studies including adult civilian trauma patients comparing in-hospital whole blood to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro was used to assess quality of evidence and risk of bias. The study was registered on PROSPERO (#CRD42023451143). RESULTS: A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., ED, 3-, or 6-hour), 24-hour, late (i.e., 28- or 30-day), and in-hospital. On meta-analysis, whole blood was not associated with decreased mortality. Whole blood was associated with decreased 4-hour RBC (mean difference -1.82, 95% CI -3.12 to -0.52), 4-hour plasma (mean difference -1.47, 95% CI -2.94 to 0), and 24-hour RBC transfusions (mean difference -1.22, 95% CI -2.24 to -0.19) compared to component therapy. There were no differences in infectious complications or ICU length of stay between groups. CONCLUSION: We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE: Level III, Guidelines.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

BACKGROUND: This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION: When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Routine post-operative labs and healthcare system burden in acute appendicitis.

BACKGROUND: Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS: A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS: A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS: In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.

Alcohol withdrawal syndrome in trauma patients: a study using the Trauma Quality Program Participant User File.

Objective: To identify the rates and possible predictors of alcohol withdrawal syndrome (AWS) among adult trauma patients. Methods: This is a retrospective review of all adult patients (18 years or older) included in the 2017 and 2018 American College of Surgeons Trauma Quality Program Participant User File (PUF). The main outcomes were rates and predictors of AWS. Results: 1 677 351 adult patients were included in the analysis. AWS was reported in 11 056 (0.7%). The rate increased to 0.9% in patients admitted for more than 2 days and 1.1% in those admitted for more than 3 days. Patients with AWS were more likely to be male (82.7% vs. 60.7%, p<0.001), have a history of alcohol use disorder (AUD) (70.3% vs. 5.6%, p<0.001) and have a positive blood alcohol concentration (BAC) on admission (68.2% vs. 28.6%, p<0.001). In a multivariable logistic regression, history of AUD (OR 12.9, 95% CI 12.1 to 13.7), cirrhosis (OR 2.1, 95% CI 1.9 to 2.3), positive toxicology screen for barbiturates (OR 2.1, 95% CI 1.6 to 2.7), tricyclic antidepressants (OR 2.2, 95% CI 1.5 to 3.1) or alcohol (OR 2.5, 95% CI 2.4 to 2.7), and Abbreviated Injury Scale head score of ≥3 (OR 1.7, 95% CI 1.6 to 1.8) were the strongest predictors for AWS. Conversely, only 2.7% of patients with a positive BAC on admission, 7.6% with a history of AUD and 4.9% with cirrhosis developed AWS. Conclusion: AWS after trauma was an uncommon occurrence in the patients in the PUF, even in higher-risk patient populations. Level of evidence: IV: retrospective study with more than one negative criterion.

The extent to which geography explains one of trauma's troubling trends: Insurance-based differences in appropriate interfacility transfer.

BACKGROUND: A growing body of literature suggests the persistence of a counterproductive triage pattern wherein uninsured adults with major injuries presenting to nontrauma centers (NTCs) are more likely than insured adults to be transferred. Geographic differences are frequently blamed. The objective of this study was to explore geography's influence on variations in insurance transfer patterns, asking whether differences in distance and travel time by road from NTCs to the nearest level 1 or 2 trauma center alter the effect. As a secondary objective, differences in neighborhood socioeconomic disadvantage were also assessed. METHODS: Adults (16-64 years) with major injuries (Injury Severity Score, >15) presenting to NTC emergency departments (EDs) were abstracted from 2007 to 2014 state inpatient/ED claims. Differences in the risk-adjusted odds of admission versus transfer were compared using mixed-effect hierarchical logistic regression and spatial analysis. RESULTS: A total of 48,283 adults presenting to 492 NTC EDs were included. Among them, risk-adjusted admission differences based on insurance status exist (e.g., private vs. uninsured odds ratio [95% confidence interval], 1.60 [1.45-1.76]). Spatial analysis revealed significant geographic variation ( p < 0.001). However, in contrast to expectations, the largest insurance-based discrepancies were seen in less disadvantaged NTCs located closer to larger trauma centers. Stratified analyses comparing the closest versus furthest distance, shortest versus longest travel time, and least versus most deprived populations agreed, as did sensitivity analyses restricting uninsured transfer patients to those who remained uninsured versus subsequently became insured. CONCLUSION: Adults with major injuries presenting to NTCs were less likely to be transferred if insured. The trend persisted after accounting for differences in access to care, revealing that, while significant geographic variation in the phenomenon exists, geography alone does not explain the issue. Taken together, the findings suggest that additional and potentially subjective elements to insurance-based triage disparities at NTCs are likely to exist. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level III.

Improved outcomes using laparoscopy for emergency colectomy after mitigating bias by negative control exposure analysis.

BACKGROUND: Laparoscopy is superior to open surgery for elective colectomy, but its role in emergency colectomy remains unclear. Previous studies were small and limited by confounding because surgeons may have selected lower-risk patients for laparoscopy. We therefore studied the effect of attempting laparoscopy for emergency colectomies while adjusting for confounding using multiple techniques in a large, nationwide registry. METHODS: Using National Surgical Quality Improvement Program data, we identified emergency colectomy cases from 2014 to 2018. We first compared outcomes between patients who underwent laparoscopic versus open surgery, while adjusting for baseline variables using both propensity scores and regression. Next, we performed a negative control exposure analysis. By assuming that the group that converted to open did not benefit from the attempt at laparoscopy, we used the observed benefit to bound the effect of unmeasured confounding. RESULTS: Of 21,453 patients meeting criteria, 3,867 underwent laparoscopy, of which 1,375 converted to open. In both inverse probability of treatment weighting and regression analyses, attempting laparoscopy was associated with improved 30-day mortality, overall morbidity, anastomotic leak, surgical site infection, postoperative septic shock, and length of hospital stay compared with open surgery. These effects were consistent with the lower bounds computed from the converted group. CONCLUSION: Laparoscopic surgery for colorectal emergencies appears to improve outcomes compared with open surgery. The benefit is observed even after adjusting for both measured and unmeasured confounding using multiple statistical approaches, thus suggesting a benefit not attributable to patient selection.

Effect of Antibiotic Duration in Emergency General Surgery Patients with Intra-Abdominal Infection Managed with Open vs Closed Abdomen.

BACKGROUND: Data on duration of antibiotics in patients managed with an open abdomen (OA) due to intra-abdominal infection (IAI) are scarce. We hypothesized that patients with IAI managed with OA rather than closed abdomen (CA) would have higher rates of secondary infections (SIs) independent of the duration of the antibiotic treatment. METHODS: This was an observational, prospective, multicenter, international study of patients with IAI requiring laparotomy for source control. Demographic and antibiotic duration values were collected. Primary outcomes were SI (surgical site, bloodstream, pneumonia, urinary tract) and mortality. Statistical analysis included ANOVA, chi-square/Fisher's exact test, and logistic regression. RESULTS: Twenty-one centers contributed 752 patients. The average age was 59.6 years, 43.6% were women, and 43.9% were managed with OA. Overall mortality was 16.1%, with higher rates among OA patients (31.6% vs 4.4%, p < 0.001). OA patients had higher Sequential Organ Failure Assessment (4.7 vs 1.8, p < 0.001), American Society of Anesthesiologists Physical Status (3.6 vs 2.7, p < 0.001), and APACHE II scores (16.1 vs 9.4, p < 0.001). The mean duration of antibiotics was 6.5 days (8.0 OA vs 5.4 CA, p < 0.001). A total of 179 (23.8%) patients developed SI (33.1% OA vs 16.8% CA, p < 0.001). Longer antibiotic duration was associated with increased rates of SI: 1 to 2 days, 15.8%; 3 to 5 days, 20.4%; 6 to 14 days, 26.6%; and more than 14 days, 46.8% (p < 0.001). CONCLUSIONS: Patients with IAI managed with OA had higher rates of SI and increased mortality compared with CA. A prolonged duration of antibiotics was associated with increased rates of SI. Increased antibiotic duration is not associated with improved outcomes in patients with IAI and OA.

Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary.

BACKGROUND: Syncope is a commonly suspected cause of injury. Patients often undergo extensive testing without proven benefit. In this study, we investigated the utility of an inpatient syncope workup. METHODS: A retrospective review was performed of all admissions to a Level I trauma center after fall or motor vehicle collision in patients older than 50 years and in whom syncope was suspected for the 3-year period ending December 2008. Demographics, diagnostic workup, number of abnormal results, and the frequency of subsequent interventions were recorded. RESULTS: Two thousand one hundred seventy-one patients fulfilled study entry criteria; syncope was suspected in 302. The syncope and nonsyncope groups, respectively, were similar in age (76.9 years±12 years vs. 74.8 years±13 years) and female gender (58.3% vs. 58.4%) but differed in Injury Severity Score (7.4±5.7 vs. 9.7±7.7; p<0.01). Diagnostic workup commonly included electrocardiogram (89.4%), cardiac enzymes (88.7%), echocardiogram (78.8%), and carotid duplex or computed tomography angiography (64.9%). Significant abnormal results were uncommon: cardiac enzymes (2.9%), echocardiogram (3.8%), and carotid imaging (4.6%). Overall only 42 patients (13.9%) required further intervention, and in 29 patients (69%), the intervention was based on the initial history, physical examination, or admitting electrocardiogram. CONCLUSION: Routine inpatient syncope workup has a low yield. Our data suggests that the diagnostic workup should be ordered based on clinical information rather than a standardized workup for all patients with suspected syncope.

Can acute care surgeons perform emergency colorectal procedures with good outcomes?

BACKGROUND: Acute care surgeons (ACS) perform emergency colorectal procedures but may have lower case volumes when compared with their general surgical and colorectal colleagues, which may compromise outcomes. In the acute populations, the elderly may be at particular risk. METHODS: Records of all elderly patients (age >65 years) presenting to a tertiary center with a colorectal emergency requiring operation over a 7-year period were reviewed. Data abstracted included presenting characteristics, pre- and postoperative diagnosis, procedural details, surgeon, and outcomes. Surgeons were stratified based on the number of elective colorectal cases they performed over the same time period. Chi-square test, Fisher's exact test, and t test were used, and logistic regression models controlled for patient characteristics. p < 0.05 was significant. RESULTS: There were 293 emergent colorectal operations. Mortality before stratification for perioperative risk factors was 15% (43 of 293). ACS mortality was higher than other surgeons (23.2% versus 12.4%; odds ratio, 2.14; p = 0.034). Length of stay, intensive care unit length of stay, and ventilator days were longer for ACS although not significant. On risk stratification by multivariate analysis preoperative hypotension, American Society of Anesthesiology class, age, time to operating room, and management with an open abdominal technique predicted mortality but surgeon type did not. CONCLUSIONS: ACS caring for colorectal emergencies encounter critically ill patients with significant comorbidities, often from extended care facilities. If patient characteristics are considered when scrutinizing outcomes of emergency colorectal procedures, ACS perform as well as their colleagues who perform a higher volume of elective resections.

Risk of venous thromboembolism after spinal cord injury: not all levels are the same.

BACKGROUND: Venous thromboembolism (VTE), a diagnosis that includes both deep vein thrombosis and pulmonary embolism, is a well-recognized complication following injury. Previous studies have identified multiple risk factors including spinal cord injury (SCI). We hypothesized that the level of SCI also influences the likelihood of VTE. METHODS: The National Trauma Data Bank was queried to identify all patients with SCI admitted in 2007 and 2008. Rates of VTE, demographics, admitting comorbidities, in-hospital complications, level of SCI (divided by National Trauma Data Bank into five groups), associated injuries, and outcome variables were abstracted. Multiple regression was used to identify independent risk factors for VTE. RESULTS: During the 2-year period, 18,302 patients were admitted with SCI. The overall rate of VTE was 4.3% but varied significantly depending on the level of SCI injury (χ(2), 44.8; p < 0.05). Patients with high cervical spine (C1-4) injury had a rate VTE of 3.4%, whereas patients with high thoracic spine (T1-6) injury had the highest rate of VTE at 6.3%. The lowest rate of VTE was in patients with lumbar injury (3.2%). There were no significant differences in the preexisting comorbidities or in-hospital complications among the five SCI groups with the exception of pneumonia. In a multiple logistic regression model, the level of SCI was an independent risk factor for VTE as was increasing age, increasing Injury Severity Score, male gender, traumatic brain injury, and chest trauma. CONCLUSIONS: The rate of VTE differs with various SCI levels. Patients with high thoracic (T1-6) injury seem to be at the highest risk and patients with high cervical (C1-4) injury at one of the lowest. A higher index of suspicion for VTE should therefore be maintained in patients with a high thoracic SCI. Further studies are required to elucidate the underlying mechanisms.